HomeMy Public PortalAbout5611 GOLDEN WEST AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure,'Q,
a certificate of Workers' Compensatip)n Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES , BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING W
Certified copy is filed with the county building mspec_ ADDRESS (� [ DL'L�P�C.1 eQ7-
tion department NUMBER FIXTURE OR ITEM @ FEE p
1 � LOCALITY
WATER CLOSET
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST L /Q
COMPENSATION INSURANCE ' SHOWER OWNER Ls , C P IA) T-0 u
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars (;100)or less.) C LAVATORY ADDRESS
I certify that in the performance of the work for which this "
permit is issued, I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Worker 'Compens i Laws DISHWASHER '
CONTRACTOR
Date lue Applicant CLOTHES WASHER
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS ,9 w Mpn r0
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation-provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL NO (�„f�
with comply with such provisions or this permit shall be STATEI/� LIC
deemed revoked 'WATER HEATER LICENSE NO �/� ,?Z CLASS C 3
LICENSED CONTRACTORS DECLARATION DISTRICT NO OCESED BY
I hereby affirm that t am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �—
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �' �
and Professions Code, and my license is in full force and effect 5 PER SYSTEM FINAL
DATE VALIDATION u
License Number -` Lic Class
U
FINAL Q
Contractor V
Date QUA)e f S'I� BY I-.
❑ •1 am exempt under Sec .B d
O� N
B 8P C for this reason
Plan check fee y1 ,
Date
PLUMBING PERMIT ISSUING FEE$ G y O
Signature
TOTAL FEE O
SINGLE FAMILY
Plan check applicant
" '
HOME OWNER-BUILDER DECLARATION Name ;9 2'8 6 2 R
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and
0 0 0 0 0 5
Professions Code) City Tel No
❑ 1, as owner of the property, will do the work and the 2t° - 2 5
structure is not intended or offered for sale (Section ° ° 0 2 8 5 0=
7044, Business and Professions Code) ► v '
CONSTRUCTION LENDING AGENCY 1061,5-83
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097, Civ C )
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authors represents Ives of this County to enter upon the
above- entioned r perty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
SUS %SI�I��
Signature of Permittee .Date